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2-� �"�'. <br /> ��--�- Application for Exemption FoRM <br /> NBbraska Department tlf <br /> REVENUE from Motor VehicleTaxes by�ualifying Nonprofit Organizations 457 <br /> •7o be filed with your county treasurer. <br /> ••.• � •Read instructions on reverse side. <br /> ApplicanYs Name Type oY Ownership <br /> GRAND 15LAND EVANGELICAL FREE CHURCH �tvonprotit <br /> Street or Other Mailing Address County Corporation <br /> 2609 S BLAINE ST I-iALL �pther(specify): <br /> City State Zip Code State Where Incorporated <br /> GRANp ISLAND NE 688D1 NE <br /> IDENTIFY QFFICERS,DIRECTORS,OR PARTNERS pFTHE NONPROFIT ORCANIZATION <br /> Title Name,Address,City,State,Zip Code <br /> �, r Cu�,.�' r.s..«.. C> r��- =- o- �C>`� t}?� �oA_�� �L��.M.r �V��-__. �°�`���-4\ <br /> r ..�.svr �CL--�. ..a r� :c c v e 4�c�.� '� n�:utt ��L <br /> DESCRIPTION OF THE MOTOR VEHICLES <br /> •Attach an additional sheet,if necessery. <br /> Registration Date or <br /> MotorVenicle Make �odelYear 9odyType VehiCle ID NUmber i7aie vf F�cquisiiion, <br /> if Newly Purchased <br /> �-..- �:�an�� a�� =��.�o :..z .w.� �.,n '�F � � ��.. `� -, <br /> '�dre1� `°.0 4S r.� \°.`t'� G �� .t�ac 1� �s :�t�U i��ti� <br /> `MG ti�1 r �3�GD alCl�' �l�x't S o-;<-: l��-,,. 'i ��\Ca'a`��..'.aw'�U `�',��O - - _ <br /> arP 4 - ,ca� +�v `�`L'�� E\ ��. <br /> Exempt Uses of Moror Vehicle� Are the motor vehicles u5ed exclusively <br /> �Agricultural/Worticultural ❑Educational �Religious ❑Charitable ❑Cemetery as indicated? <br /> Give detalled description of use,including an explanation if multiple use classiiications exist: �YES �NO <br /> ��.�,,,_5�,�. ���,�\��c�,���C s � �����-�-� �v c ��z�5. If No,give percentage of exempt use� <br /> �C�Ii��D <br /> NOV 3 0 2011 <br /> llnder penalties of law,I declare that I have examined this applicetion and that it is,to the best of my knowledge and belie true,complete,and correct.I <br /> also declare that I am duly authorized to sign this exemption application,and that the organization owning the above-Iisted rvperty does not discriminate <br /> in membership or employment based on race,color,or na�ional origin. HAI_L COUNTY <br /> 7RrP�S!.JR�F2S OFFIC%E <br /> GF;�-,•i�)' :F,�JC7,!J�=.�i�AS'1<A <br /> __�....,...__.r... ----° <br /> sign � � <br /> ,��, �,�.�...���� �.\�.�. �,. <br /> here Aut�io ized Signature Title pate <br /> _�._ w� __ —�-, <br /> �� � FOR COUNTYTREASURER RECOMMENDA7IQN _ _ J <br /> �PPROVAL COMMENTS: sS ���°�'U°� <br /> �]DISAPPROVAL <br /> \ �L`�JL� /'�� /ar�-�-9—!� <br /> Signature of County Treasure� Date <br /> FpR COUN7Y BOARD OF E�UALIZATION USE ONLY <br /> �APPROVAL COMMENTS: <br /> ❑DISAPPROVAL <br /> /�!� <br /> Authorized Signatur Date <br /> Nebraska Oepartmont of Fievenue Authorized by Neb.Rev.Stat.§§77-209(1)(c)and(d),and 60-3,185,end 60-3,189 <br /> 9fi-253•2006 Rev.B-2011 Suparsedes 96-253-2006 Rev.5-2009 <br /> PLEAS�RE7AIN A COPY FQRYpUR RECORDS. <br />